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Quality and Outcomes Framework: what have we learnt?

BMJ 2016; 354 doi: (Published 04 August 2016) Cite this as: BMJ 2016;354:i4060

Chinese translation


  1. Martin Roland, professor of health services research1,
  2. Bruce Guthrie, professor of primary care medicine2
  1. 1Institute of Public Health, Cambridge CB2 0SR, UK
  2. 2Population Health Sciences, University of Dundee, Dundee, UK
  1. Correspondence to: M Roland mr108{at}

Martin Roland and Bruce Guthrie assess the successes and failures of the pay-for-performance scheme and what its future should be

In 2004 the UK National Health Service introduced the largest health related pay-for- performance scheme in the world—the Quality and Outcomes Framework (QOF).1 However Scotland is now abandoning the scheme, and growing disenchantment in England is likely to lead to major changes. What have we learnt, and what should happen to QOF in future?

Promising start

In the late 1990s, general practitioners’ pay had fallen substantially behind that of specialists, and morale and recruitment in general practice were poor. The government and the British Medical Association (BMA) privately agreed that a large pay rise was needed. Money was available because in 2000 the government had committed to increasing NHS spending to mid-European levels as a percentage of gross domestic product. However, the profession had to give something in return, and the BMA dropped its longstanding opposition to “quality payments” and started to negotiate a pay-for-performance scheme that would substantially increase funding for general practice.

There followed 18 months of negotiations between BMA and NHS Employers with a small number of clinical advisers to develop the outcome measures (indicators) that would form the basis of the scheme (box 1). A starting premise was that the clinical indicators should be based on evidence based guidelines so that they would be likely to command a wide degree of professional support (box 2). The framework also included indicators related to practice organisation and patient participation. The package was controversial, and the BMA allowed its members to vote on the scheme—once in outline and once when the details were known.

Box 1: How the Quality and Outcomes Framework works

  • The original scheme included 76 clinical indicators covering 10 conditions

  • Data on clinical quality were extracted automatically from practice electronic records

  • Doctors could exclude patients from …

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